Provider Demographics
NPI:1770775074
Name:EVERRETT, VICTORIA M (RD LD CNSC CDE)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:M
Last Name:EVERRETT
Suffix:
Gender:F
Credentials:RD LD CNSC CDE
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:M
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LD
Mailing Address - Street 1:122 ISLAND VIEW RD
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-8436
Mailing Address - Country:US
Mailing Address - Phone:360-417-7125
Mailing Address - Fax:360-417-7188
Practice Address - Street 1:939 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3909
Practice Address - Country:US
Practice Address - Phone:360-417-7125
Practice Address - Fax:360-417-7188
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA02026133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1940592Medicare UPIN